RHEC Members

Evaluation of the National Partnership for Action to End Health Disparities

National Partnership for Action_Attachment C

RHEC Members

OMB: 0990-0406

Very Dissatisfied

Dissatisfied

Neither Satisfied nor Dissatisfied

Satisfied

Very Satisfied

Have not used/Don’t Know Enough to Assess

Leadership provided by OMH staff

Assistance with communications and other media-related activities

Assistance with collecting data, using data, and evaluating progress toward your RHEC’s goals

Assistance with coordination and facilitation of meetings and other exchanges

Follow-up on requests for assistance

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0990-0406 can be found here:

2016-03-25 - Extension without change of a currently approved collection

Document [docx]

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Attachment C: RHEC Survey

Form Approved OMB No. 0990-XXXX

Exp. Date XX/XX/XXXX
HEC Survey

Introduction: Welcome to the survey being conducted by Community Science on behalf of the Office of Minority Health in the U.S. Department of Health and Human Services. This survey is designed to collect information on your involvement with efforts to end health disparities, including the National Partnership for Action to End Health Disparities. Your participation is voluntary. You can decline to participate. You can also stop your participation at any time by choosing not to submit your responses.

Your name and organization will not be attached to specific comments that you share today. Your response may be included with those of other respondents in aggregate form in reports or journal articles. In addition, participants’ names will not be included in any information viewed by officials at the Office of Minority Health or any other HHS agency.

Methods will also be taken to protect study data. Data from the survey and interviews will not identify any person. Data from the surveys and interviews will be stored in a password-protected database. Only authorized Community Science staff working on the evaluation will have access to the database. The briefs and reports produced for the evaluation will not identify specific individuals. All potentially identifying information will be destroyed at the study’s conclusion.

Please select which region your organization is located in:

□ Region 1 (CT, MA, ME, NH, RI, VT)

□ Region 2 (NJ, NY, PR, USVI)

□ Region 3 (DC, MD, PA, VA, WV)

□ Region 4 (AL, FL, GA, KY, MS, NC, SC, TN)

□ Region 5 (IL, IN, MI, MN, OH, WI)

□ Region 6 (AR, LA, NM, OK, TX)

□ Region 7 (IA, KS, MO, NE)

□ Region 8 (CO, MT, ND, SD, UT, WY)

□ Region 9 (AZ, CA, GU, HI, NV)

□ Region 10 (AK, ID, OR, WA)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

How long have you been involved with the Regional Health Equity Council (RHEC)?

__ year(s) __month(s)

For each item below, please indicate the degree to which you agree or disagree with the following statements:

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
The RHEC has a clear mission and set of goals.	1	2	3	4	5
The RHEC has a clear and efficient decision-making process.	1	2	3	4	5
Communication among RHEC members is clear and effective.	1	2	3	4	5
The RHEC actively engages in activities that help achieve the 5 goals and implement the 20 strategies of the National Partnership for Action (NPA).	1	2	3	4	5
The RHEC follows through consistently on its activities (e.g., outstanding tasks are dealt with in a timely manner).	1	2	3	4	5
RHEC members work together to solve shared problems and overcome obstacles to their progress.	1	2	3	4	5
The RHEC has a clear strategy and set of actions for engaging and supporting state and local community agencies and organizations.	1	2	3	4	5
The RHEC has a clear strategy and set of actions for using data to inform decisions.	1	2	3	4	5
The RHEC has a comprehensive strategy that reflects its blueprint for action/workplan.	1	2	3	4	5
RHEC members have a clear understanding of their roles and responsibilities in implementing the RHEC’s blueprint for action/workplan.	1	2	3	4	5
RHEC members share information about strategies and actions in their organizations or communities to end health disparities and achieve health equity.	1	2	3	4	5
RHEC co-chairs and Subcommittee chairs are able to mobilize and move the RHEC agenda forward.	1	2	3	4	5
RHEC members have the skills, knowledge, and access to resources needed to implement planned activities.	1	2	3	4	5
RHEC members serve as information and resource brokers and consultants (e.g., sharing data, technical assistance, best practices) to non-RHEC organizations in order to support the sustainability, effectiveness, and growth of efforts to reduce health disparities.	1	2	3	4	5
RHEC members leverage resources and assets to work more effectively to implement the RHEC’s blueprint for action/workplan.	1	2	3	4	5

Do you currently serve on a RHEC Subcommittee?

No (skip to question 5)
Yes

Please indicate the degree to which you agree or disagree with the following statements.

	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree
Subcommittee members have a clear understanding of their roles and responsibilities in implementing the RHEC’s blueprint for action/workplan.	1	2	3	4	5
Subcommittee members have a clear and efficient decision-making process.	1	2	3	4	5
Communication among Subcommittee members is clear and effective.	1	2	3	4	5
The Subcommittee plans and actively engages in activities that help achieve the RHEC’s goals.	1	2	3	4	5
The Subcommittee follows through consistently on its activities (e.g., outstanding tasks are dealt with in a timely manner).	1	2	3	4	5

Has the RHEC achieved the goals it set out to achieve?

Not at All	A Little	Moderately	Significantly	Completely	Don’t Know Enough to Rate
0	1	2	3	4	5

Have the Subcommittees, on the whole, achieved the goals they set out to achieve?

Not at All	A Little	Moderately	Significantly	Completely	Don’t Know Enough to Rate
0	1	2	3	4	5

Did you work or collaborate with another RHEC member agency or organization on non-RHEC activities as a result of your participation in the RHEC?

No (skip to question 11)
Yes

Please list the names of the other RHEC member agency(cies) or organization(s) that you worked or collaborated on non-RHEC activities with as a result of your participation in the RHEC.

____________________
____________________

For each agency listed, please answer the following questions [questions 9 and 10 will be repeated for the number of agencies listed]

Was this the first time you worked or collaborated with a person from (name of listed agency)?

What did you do together? (please check all that apply)

Exchanged information about a policy, procedure, or practice to end health disparities
Planned a joint grant program or initiative to end health disparities
Combined funds and other resources to support efforts to end health disparities
Was referred to another person in the RHEC member’s agency or organization who worked with me on an effort to end health disparities
Developed and submitted a proposal to support an effort to end health disparities
Other (please describe: ____________________________________________ )
Other (please describe: ____________________________________________ )

Did you influence any program or organizational policies, procedures, or practices to end health disparities in your agency or organization?

No (skip to question 13)
Yes (please describe the results of your influence:________________________________)

Did your participation in the RHEC have anything to do with this influence?

No
Yes (please explain: _______________________________________________)

Did your participation in the RHEC help you develop or strengthen your program, agency, or organization’s relationship with or support for the following (please check all that apply):

Federal representatives in your region
Regional organizations or coalitions (besides the RHECs) working to end health disparities
State agencies, organizations, or coalitions working to end health disparities
Tribal leaders or organizations working to end health disparities
Philanthropic organizations working to end health disparities
Businesses working to end health disparities
City or county agencies, organizations, or coalitions working to end health disparities
Rural organizations or coalitions working to end health disparities
Grassroots organizations or coalitions working to end health disparities
Other (Please describe:___________________________________________________)

How satisfied have you been with the following kinds of support provided for the RHEC?

*(if answered “Don’t Know Enough to Assess” to all of the last 4 questions, skip to question 17)

What support or assistance has been most helpful?

__________________________________________________________________________________

What has been least helpful?

_________________________________________________________________________________

What would you recommend to improve support and technical assistance to the RHEC?

_________________________________________________________________________________

Please identify representatives from state and/or local community agencies and organizations with whom you communicate about the NPA and whom we might contact for more information about their health disparities work.